Correspondence Address:Tadele AmareDepartment of Psychiatry, College of Medicine and Health Science, University of Gondar, Gondar Ethiopia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_39_17

Abstract

Background: Suicide is the act of intentionally causing one's own death. Global, estimation of suicide and suicidal behavior is leading cause of death and burden of diseases which is also the third leading cause of death in prison. It is a common mental health problem, and the magnitude is high especially in countries where mental health service is poor. Suicide ideation is the leading cause to commit suicide. However, there is lack of study regarding suicide in prison in African countries including Ethiopia. Objectives: The aim of this study was to assess the prevalence of suicidal ideation and associated factors among prisoners in Addis-Ababa correctional center Addis Ababa, Ethiopia, 2015. Methods: An institution-based cross-sectional study was conducted from April to June 2015. Systematic random sampling technique was used to get a total of 423 samples of prisoners. After obtaining ethical clearance from the University of Gondar and Amanuel Mental Specialized Hospital and verbal consent from the respondents, data were collected. The collected data were coded, entered, and cleaned by Epi Info version 7 and exported to SPSS version 20 for analysis. The strength of association was presented by odds ratio with 95% confidence interval (CI). The independent variables that fulfill P < 0.2 in the bivariate logistic regression analysis were entered to multivariable logistic regression analysis by enter method. Variables with P < 0.05 in multivariable logistic regression analysis were considered as have statistically significant association with dependent variables. Result: A total of 423 prisoners participated with 100% response rate. The magnitude of suicidal ideation in the last 1 month was 35 (8.04%); 95% CI (5.6–11.1). Being male (AOR = 2.962, 95% CI [1.307, 6.712]), perceived stigma (AOR = 2.666, 95% CI [1.161, 6.122]), and family history of suicide (AOR = 2.291, 95% CI [1.736, 7.129]) was associated with suicide ideation. Conclusions and Recommendations: The magnitude of suicide ideation in prisoners was higher than the general population. Hence, special attention pertaining to suicide prevention; should be given for prisoners.

Suicide is a fatal act that represents the person's wish to die. There is a range between thinking about suicide and acting it out; some persons have ideas of suicide that they will never act, some plan for days weeks or even years before acting.[1]

Globally, suicide has become a major public health problem. The World Health Organization; data indicate that approximately one million people die worldwide by suicide in each year. There is one death by suicide every 40 s.[2] In the world, the prevalence of suicidal ideation is 10%–14%. Suicide is a huge but largely preventable health problem; economically, it costs in billions of dollars every year.[3] Estimation indicated that 8.3 million adult persons in the United States reported having suicidal thought in the past years.[4] Suicide is the single most common cause of death in correctional settings, jails, prisons, and penitentiaries are responsible for preventing the health and safety of their inmate population.[5] More than 10 million people are prisoners worldwide with the number of people in prison increasing worldwide to more than one million in the past decade. However, suicide prevention is a major challenge for penal institutions in many countries.[6] The suicide rate in prisons and jails are 3 to 9 times higher than suicide in the general population.[7] In the United States, approximately 200 prison suicides occur each year, and suicide is the third leading cause of death in prison.[8] Suicide is a sentinel event in prison, preventive efforts reflect the adequacy and comprehensiveness of mental health, psychiatric, custodial, and administrative services in prison.[9]

The magnitude of suicide ideation in the community study in the United States was 3.7% in the past 12 months. It was higher between the age of 18 and 29 years old.[5] A school-based survey in Thailand was 8.8% in the past 12 months [10]. In Guyana school students, suicide ideation was 18.4% in the past 12 months.[11] In Britain community-based survey suicide ideation in the past week was 0.4%.[12] In Kasha prisoners (Iran), on the prevalence of suicidal ideation was 44.6%.[13] In New South Wales, Australia prisoners the prevalence of suicidal ideation in their lifetime was 33.7%.[14] In England and Wales, among male remand prisoners suicide ideation in the week before the interview was 12%.[15] In Chicago, female prisoners' suicidal ideation in their lifetime was 53.4%.[16]

Factors that associated with suicidal ideation were being single and education level among Kasha prisoners.[13] Suicide risk factors specific to correctional settings were unsentenced states, inmate-related conflict, and length of sentenced. In the United Kingdom and Australia, one in ten complete suicides in prison occurs within the first 24 h of in prisonment and one-third with in first few weeks.[14] In the United States jail, hopelessness, aggression, impulsivity, low reason for living, low social support, and low self-steam have found to be associated with suicidal ideation.[14] Suicide in prison seems to increase with long-term stay or sentenced, family conflict, and poor social support.[5] However, suicide in prison is a neglected public health issue especially in middle- and low-income countries including Ethiopia. The true impact of the problem and its magnitude are significantly underreported and underestimated. Therefore, this study was intended to determine the magnitude and associated factors of suicide ideation among prisoners.

Methods

Study design and setting

The institution-based cross-sectional study was conducted from May 1 to 30, 2015. The study was conducted at Addis-Ababa correctional center which is one of the Federal Prison Correctional Centers found in Akaki Kality Sub City, Addis-Ababa, Ethiopia. In the prison, there were about 4100 sentenced prisoners of whom 3500 are males and 600 females those had got court decision for different types of crimes.

Source population included all females and males sentenced prisoners found in Addis-Ababa correctional center. The sample size required for this study was 423 determined using single population proportion formulas by taking 50% and considering 5% margin of error and with the following assumptions:

Where,

P = 50% because no similar study was done in our country among prisoners.

n = sample size

α = Level of significance 5% (α =0.05), Zα/2=1.96

d = Margin of error = 5% (d = 0.05).

Nonresponse = 10%

Then add 10% (384 × 0.1 = 38.4 ≈ 39) to compensation-respondents, so the total sample size for this study was 384 + 39 = 423.

A systematic random sampling technique was used to select the sampling units. Data was collected on presence of suicidal ideation expressed by the individual in the past 1 month. Sociodemographic factors, psychosocial factors and prison-related factors, social support and perceived stigma were considered. Data was collected by interviewing prisoners using semi-structured questionnaire.

Operational definition

Suicidal ideation

Is defined as if the respondent answers to the question have you seriously thought about committing suicide in the last 1 month? If yes, the respondent has suicidal ideation.

Social support

According to Oslo scale score:

3–8: Poor social support

9–11: Moderate support and

12–14: Strong support.

Perceived stigma

If the individual scored one and >1 he has perceived stigma.

Data processing and analysis

First, data were checked for completeness and consistency and then coded and entered into a computer using Epi Info version 3.5.3 software (Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US)) and finally exported to and analyzed using Statistical Package for Social Sciences for Windows, Version 20. (Chicago, IBM SPSS Inc.). Descriptive statistics was used to estimate the magnitude of suicide ideation to describe the variables. The bivariate and multivariable logistic regression analysis was conducted to identify factors associated with suicidal ideation among prisoners. The strength of association was presented by odds ratio with 95% confidence interval (CI). The independent variables that fulfill P < 0.2 in the bivariate logistic regression analysis were entered to multivariable logistic regression analysis by enter method. Variables with P < 0.05 in multivariable logistic regression analysis were considered as have statistically significant association with dependent variables. Ethical clearance was obtained from the Institution Review Board of College of Medicine and Health Science, University of Gondar and from Amanuel Mental Specialized Hospital. Permission was obtained from Federal Prison and Addis-Ababa correctional center administration. Informed consent was obtained from the study participants. The right to refuse at any time they want and the chance to ask anything about the study was given for the study participants and confidentiality was assured.

Result

Sociodemographic characteristics of study participants

Among the study participants, 212 (50.1%) were males and the rest were females. The age of study participants range from 18 to 72 years, and the mean age was 27.6 (SD; ± 10.6) years. Majority of prisoners 253 (59.8%) included in the study were in the age category of 18–27 years and the minority 6 (1.4%) were aged ≥58 years [Table 1].

Characteristics of social support and stigma of the study participants

[Figure 1] shows the perception of prisoners regarding social support. 185 (43.7%) had poor social support and 72 (17.0%) had strong social support. Among those who had poor social support, 17 (48.6%) experienced suicidal ideation.

Figure 1: Social support and suicide ideation among prisoners in Addis Ababa correction center, 2015

Characteristics of family history of suicide of the respondents' prisoners in Addis-Ababa prison

Among the study participants, 25 (5.9%) had a family history of suicide and 398 (94.1%) prisoners had no family history of suicide.

Characteristics of length of stay in prison of the respondent in Addis-Ababa prison

In [Figure 2], about 184 (43.5%) stayed for 2 to 5 years in the prison whereas 40 (9.5%) were in prison for 6 to 10 years. 18 (51.4%) prisoners who had suicidal ideation were in prison since 2 to 5 years.

195 (46.1%) prisoners were imprisoned for cheating, 182 (43%) for theft, 23 (5.4%) for murder, 13 (3.1%) for being gangsters and 10 (2.4%) for to drug trafficking.

Magnitude of suicidal ideation among prisoners in Addis-Ababa prison in the last 1 month

The magnitude of suicidal ideation was 35 (8.04%) with 95% CI (5.6%–11.1%) in the last 1 month.

Factors associated with suicidal ideation in the last 1 month, among prisoners in Addis-Ababa prison

Based on the bivariate logistic regression analysis sex, religion, social support, stigma, length of sentence, and family history of suicide were taken as variables for multivariate analysis. On multivariate analysis sex, stigma, and family history of suicide were identified as statistically significant predictors for suicidal ideation. According to the multivariate logistic regression analysis, male prisoners are about three (AOR = 2.962, 95% CI [1.307, 6.712]) times more likely to develop suicidal ideation as compared to female prisoners in the last month before the data collection period. Prisoners who perceived social stigma were 2.67 (AOR = 2.666, 95% CI [1.161, 6.122]) times more likely for developing suicidal ideation than their counterpart. The prisoners who had family history of suicide were 2.66 (AOR = 2.291, 95% CI [1.736, 7.129]) times more likely for developing suicidal thought in the last 1 month before the investigation compared to prisoners who did not have a family history of suicide [Table 2].

Table 2: Factors associated with suicidal ideation in the last 1 month, among prisoners in Addis Ababa correction, 2015

The magnitude of suicidal ideation in the past 1 month before the interview was 35 (8.08%) in Addis Ababa federal correction center. Our study finding was higher than the study done in Addis Ababa (2.7%) in general population,[17] in the United States (3.7%)[4] and Britain (3.9%) for presence of suicidal ideation in the past 12 months before the interview.[12] This finding was lower than the studies done in Iran (44.6%)[13] and Australian (33.7%) prisoners.[14] This might be due to the difference in socioeconomic and differences in socioeconomic conditions and study participants who were different from the people belonging to the general population. This study finding is consistent with the global report of 10% and 12% lifetime suicidal ideation rate [2] and 8.8% seen in the adolescents of Thailand.[10]

Prisoners who had a family history of suicide had two-fold increase in suicidal ideation when compared to prisoners who did not have family history of suicide. Prisoners who perceived social stigma were 2.67 times at higher odds for developing suicidal ideation than their counterparts. According to our study, male prisoners were three times at a higher risk for suicidal ideation as compared to female prisoners in the month before data collection. This is consistent with the finding of a study in Thailand which also showed a male preponderance for the risk of suicidal ideation.[10]

Conclusions

The prevalence of suicidal ideation among prisoners was higher than the general population. Male gender, being stigmatized and individuals with a history of suicide in family need special attention.

The limitation of this study was that comorbid medical illness and psychiatric problems were not assessed which could be important factors for increasing risk of suicidal ideation and attempt.